Foreign body nose and its removal

The nose is designed for breathing including warming, moistening and cleaning of inspired air but sometimes this passage with  holes in front becomes an object of playing of small kids. Impacion of foreign body is more likely to occur in children while playing with nostrils. Small children may insert any object into the nasal or other orifices of body out of curiosity,as an experiment or an adventure with a plan to remove it afterwards often they fail to do so.But they do not disclose it to the parents for fear of punishment until it pains a lot.Impaction of foreign body causes local oedema and if neglected there will be infection causing fluid exudate,nectrotic  tissue breakdown products, neutrophils, macrophages i.e formation of pus.
Anatomical consideration:
Nasal cavity extends from external nostrils to posterior end of nasal septum.At  four and a half weeks of intrau erine life on each side of frontal prominence just above the stomodeum a local thickening of surface ectoderm—the nasal placode develops.During the 5th week lateral and medial nasal swellings sorrond the nasal placode which forms floor of a depression—the nasal pit. The lateral swelling will form alae of nose and medial swelling will give rise to middle portion of the nose(also middle portion of upper lip and middle portion of maxilla as well as entire primary palate).Nostrils are anteriorly seperated  by a soft median portion called columella.Each nostril is pear shaped,bounded laterally by ala measuring 1’5 to 2 cm antero-posteriorly and ‘5 o 1cm transversely.Posterior nasal apertures areoval each measuring 2’5 cm vertically and 1’25 cm ransversely.Each half of nasal cavity posses a floor, a roof,a lateral wall anddivided into vestibular(just above nostril),olfactory(at superior nasal chonca) and respiratory(rest) regions.Vestibule is lined by skin wih coarse hairs(Vibrissae) and sebaceous glands.lateral wall covered by vascular mucous membrane attached to underlying periosteum is marked by 3 elevations:Superior, Middle and Inferior choncae( Turbinate bones) and and lateral o each chonca by corresponding nasal passage or meaus connected to air sinuses etc.
Age:
Children of 5-6 years are most sufferers.Infant below 18 months of age are timmune as they do not have the skills to put things into nose.
Sex:
Both sexes are equal sufferer.
Types of foreign body:
Usually round and smooth small objects but sometimes beans,kernels of corn,buttons,small wild flowers,fragmens of foam,piece of tissue paper,spherical parts of toy etc.Rough and sharp objects are painful and the child does not like to insert them.
Diagnosis:
When a child is brought by relatives or parents with complaints of purulent discharge from nose with histor of fever etc or a crying child rubbing his or her nose fanatically the attendinng doctor should exclude foreign body of the nose.However the purulent discharge is usually unilateral.If this is neglected it ma lead to pus formation of maxillary or frontal sinusitis.But luckily these remain rudimentary in infancy and start rapidly developing at the time of eruption of permanent teeth around 7 ears.
Diagnosis is made by:
1.Direct visualization of the object in the nose
2.History of incident:Report by the child or parent of inserting something in the nose
3.Unilateral purulent discharge from the nose.
4.Halitosis i.e. offensive odour of the breath
5.Age older than 18 months especially between 4-6 years
Removal:
A.Spontaneous removal:
Foreign body in the nose is irritating especially when it is wild flowers,herbal object,tissue paper etc and may initiate protective sneezing reflex which may expel it.In this process there occurs reflex secretion as
There is no use to sneeze through a dry nose.The secretion itself more irritates the nose and the trapped object may blast out of nosrtil.
However this natural phenomenon may fail in inert and well trapped object and tactful manual process is needed to get rid of it.
Case history:
While a boy of 4 years I was playing with my elder sister who pasted a small wild flower on the external side of the ala of the nose.I mimicked her but could not paste  rather pushed a wild flower in the nostril.With inspiration it went more inside giving rise to intense irritation and pain.
I started crying and my worried mother wanted to send someone to fetch my doctor father from the hospital when my grand father who was a home rushed to the spot.
He inserted a stem of a tobacco leaf which he he used to chew with ‘Pan’ in my other nostril.I immediaely sneezed violently and the foreign body blasted out.
B.Instrumenal removal:
Equipments:
1.Nasal speculum
2.Head light:Behind and to the right of the patient
3. Crocodile forceps/Curved forceps/Bayonet forceps
4.Nasal sucker
5.Cotton pledgets
6.2 %Tetracaine/2%Lignocaine Hcl with Phenylephrine—left for 10 minutes
Procedure:
Explain the patient what you are going to do and get his or her confidence.
With proper light taking the help of speculum the object must be seen clearly and blind attempt of removal should be avoided.The size,shape and type of foreign body should be determined so that it can be grasped properly avoiding
manipulating to more difficult position.Before starting the procedure the opposite nostril should be closed by pressing it and the patient should be asked to blow the nose forcefully.
This may either bring out foreign body or may make it more visible.If this fails then cotton pledget soaked with Lidocaine with Phenylephrine should be placed for 10 minutes.Crocodile forceps or other curved haemostats with rough jaws are advanced,the jawst opened and foreign body is grasped and removed.
However if the foreign body is decomposed it is removed by mild suction.Soft object e.g.waded foam etc may be removed by grasping with bayonet forceps.When bleeding occurs nostril is temponaded witht small pack of  cotton soaked with adrenaline.Antibiotics may be used if the foreign body is old with infection.
Complicaions:
Pressing the object posteriorly makes it difficult to grasp.It may be displaced into pharynx and aspirated into tracheobronchial tree requiring bronchoscopy. Sometimes posterior dislodgement with swallowing occurs which is harmless.
A living foreign body(which is common in ear and rare in nose) must be killed by drowning etc and then should be treated as an inanimate one.

 

Foreign body nose and its removal

The nose is designed for breathing including warming, moistening and cleaning of inspired air but sometimes this passage with holes in front becomes an object of playing of small kids. Impacion of foreign body is more likely to occur in children while playing with nostrils. Small children may insert any object into the nasal or other orifices of body out of curiosity,as an experiment or an adventure with a plan to remove it afterwards often they fail to do so.But they do not disclose it to the parents for fear of punishment until it pains a lot.Impaction of foreign body causes local oedema and if neglected there will be infection causing fluid exudate,nectrotic tissue breakdown products, neutrophils, macrophages i.e formation of pus. Anatomical consideration: Nasal cavity extends from external nostrils to posterior end of nasal septum.At four and a half weeks of intrau erine life on each side of frontal prominence just above the stomodeum a local thickening of surface ectodermthe nasal placode develops.During the 5th week lateral and medial nasal swellings sorrond the nasal placode which forms floor of a depressionthe nasal pit. The lateral swelling will form alae of nose and medial swelling will give rise to middle portion of the nose(also middle portion of upper lip and middle portion of maxilla as well as entire primary palate).Nostrils are anteriorly seperated by a soft median portion called columella.Each nostril is pear shaped,bounded laterally by ala measuring 15 to 2 cm antero-posteriorly and 5 o 1cm transversely.Posterior nasal apertures areoval each measuring 25 cm vertically and 125 cm ransversely.Each half of nasal cavity posses a floor, a roof,a lateral wall anddivided into vestibular(just above nostril),olfactory(at superior nasal chonca) and respiratory(rest) regions.Vestibule is lined by skin wih coarse hairs(Vibrissae) and sebaceous glands.lateral wall covered by vascular mucous membrane attached to underlying periosteum is marked by 3 elevations:Superior, Middle and Inferior choncae( Turbinate bones) and and lateral o each chonca by corresponding nasal passage or meaus connected to air sinuses etc. Age: Children of 5-6 years are most sufferers.Infant below 18 months of age are timmune as they do not have the skills to put things into nose. Sex: Both sexes are equal sufferer. Types of foreign body: Usually round and smooth small objects but sometimes beans,kernels of corn,buttons,small wild flowers,fragmens of foam,piece of tissue paper,spherical parts of toy etc.Rough and sharp objects are painful and the child does not like to insert them. Diagnosis: When a child is brought by relatives or parents with complaints of purulent discharge from nose with histor of fever etc or a crying child rubbing his or her nose fanatically the attendinng doctor should exclude foreign body of the nose.However the purulent discharge is usually unilateral.If this is neglected it ma lead to pus formation of maxillary or frontal sinusitis.But luckily these remain rudimentary in infancy and start rapidly developing at the time of eruption of permanent teeth around 7 ears. Diagnosis is made by: 1.Direct visualization of the object in the nose 2.History of incident:Report by the child or parent of inserting something in the nose 3.Unilateral purulent discharge from the nose. 4.Halitosis i.e. offensive odour of the breath 5.Age older than 18 months especially between 4-6 years Removal: A.Spontaneous removal: Foreign body in the nose is irritating especially when it is wild flowers,herbal object,tissue paper etc and may initiate protective sneezing reflex which may expel it.In this process there occurs reflex secretion as There is no use to sneeze through a dry nose.The secretion itself more irritates the nose and the trapped object may blast out of nosrtil. However this natural phenomenon may fail in inert and well trapped object and tactful manual process is needed to get rid of it. Case history: While a boy of 4 years I was playing with my elder sister who pasted a small wild flower on the external side of the ala of the nose.I mimicked her but could not paste rather pushed a wild flower in the nostril.With inspiration it went more inside giving rise to intense irritation and pain. I started crying and my worried mother wanted to send someone to fetch my doctor father from the hospital when my grand father who was a home rushed to the spot. He inserted a stem of a tobacco leaf which he he used to chew with Pan in my other nostril.I immediaely sneezed violently and the foreign body blasted out. B.Instrumenal removal: Equipments: 1.Nasal speculum 2.Head light:Behind and to the right of the patient 3. Crocodile forceps/Curved forceps/Bayonet forceps 4.Nasal sucker 5.Cotton pledgets 6.2 %Tetracaine/2%Lignocaine Hcl with Phenylephrineleft for 10 minutes Procedure: Explain the patient what you are going to do and get his or her confidence. With proper light taking the help of speculum the object must be seen clearly and blind attempt of removal should be avoided.The size,shape and type of foreign body should be determined so that it can be grasped properly avoiding manipulating to more difficult position.Before starting the procedure the opposite nostril should be closed by pressing it and the patient should be asked to blow the nose forcefully. This may either bring out foreign body or may make it more visible.If this fails then cotton pledget soaked with Lidocaine with Phenylephrine should be placed for 10 minutes.Crocodile forceps or other curved haemostats with rough jaws are advanced,the jawst opened and foreign body is grasped and removed. However if the foreign body is decomposed it is removed by mild suction.Soft object e.g.waded foam etc may be removed by grasping with bayonet forceps.When bleeding occurs nostril is temponaded witht small pack of cotton soaked with adrenaline.Antibiotics may be used if the foreign body is old with infection. Complicaions: Pressing the object posteriorly makes it difficult to grasp.It may be displaced into pharynx and aspirated into tracheobronchial tree requiring bronchoscopy. Sometimes posterior dislodgement with swallowing occurs which is harmless. A living foreign body(which is common in ear and rare in nose) must be killed by drowning etc and then should be treated as an inanimate one.